Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Peer Review, Quality Improvement

Intervention Description: To improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH.

Intervention Results: Rate of CS among electively induced women at the level II hospital decreased from 37.4% (2005) to 31.5% (2006) to 25% (2007). From 2005 to 2006, one year after hospital review was launched, there was a 5.9% decrease in CS (p<0.05)2. From 2006 to 2007, two years after hospital review was launched and supplemental changes to elective induction policies and practices were made, there was a 6.5% decrease in CS (p<0.05)2.

Conclusion: In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005.

Study Design: QE: pretest-posttest

Setting: 1 level-II maternity hospital in Ohio

Population of Focus: Nulliparous women who gave birth between January 2005 to December 20072

Data Source: Not specified

Sample Size: n=2,172

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Midwifery, HOSPITAL, Peer Review, Quality Improvement

Intervention Description: In efforts to help reduce the primary C-section rate, the hospital participated in the American College of Nurse-Midwives Healthy Birth Initiative. Strategies employed included use of intermittent auscultation, upright labor positioning, an early labor lounge, one-to-one labor support, and team huddles.

Intervention Results: The baseline nulliparous, term, singleton, vertex cesarean rate in 2015 was 29.3%. In 2016, after 1 year of implementation of the project, the hospital decreased nulliparous, term, singleton, vertex cesarean rate to 26.1%-a reduction of 10%. In 2017, the rate was decreased to 25.3%-a reduction by 3.7%.

Conclusion: The multicomponent bundle incorporated proven quality improvement strategies and engaged numerous champions and stakeholders, including midwifery students.

Setting: Urban academic hospital in the Midwest

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Peer-Review of Provider Decisions, Elective Induction Policy, Guideline Change and Implementation, PATIENT_CONSUMER, Intensive Therapy, Psychoeducation

Intervention Description: We conducted a retrospective study was conducted in the Centre Hospitalier Universitaire Vaudois (CHUV) including all births between the 1st January 1997 and 31st December 2011 to analyze the cesarean section (CS) rate using the different groups of the Robson classification in a Swiss maternity hospital.

Intervention Results: The overall CS rate was 29 %, mainly related to group 5 (multiparous with previous CS) and group 2 (nulliparous women induced or who had CS before labor). The study also shows that induction of labor on maternal request in nulliparous at term (group 2a) increased significantly the risk of CS compared to induction of labor for medical reason (p<0.001).

Conclusion: The Robson classification system appears as a simple tool for monitoring CS rates. The main strategies for reducing CS rates will be through better selection of women for VBAC (vaginal birth after caesarean) and limitation of induction of labor, especially in nulliparous women.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, Peer-Review of Provider Decisions, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Agreement for Level III Hospital to Accept All Patients, Medical Staff Integration

Intervention Description: Not available

Intervention Results: After the intervention, there was a statistically significant decrease in the number of VLBW infants born in a level II hospital (p<0.01).

Conclusion: Not available

Study Design: QE: pretest-posttest

Setting: Minnesota: Abbott-Northwestern/ Minneapolis Children’s Perinatal Center and Fairview-Southdale Hospital (Level II)

Population of Focus: All births at level II hospital

Data Source: Data source not provided.

Sample Size: Pretest (n= 2,573) Posttest (n= 2,722)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Labor Support, Midwifery, HOSPITAL, Chart Audit and Feedback, Peer Review, Quality Improvement

Intervention Description: This quality improvement initiative involved multiple interventions that were monitored over time by statistical process control charts. Components included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. The nursing team received training and certification in holistic nursing, and certified nurse-midwives were employed and given delivery privileges. The six-bed Karmanos Center for Natural Birth (NBC) was opened in November 2014 for low-risk women who were managed without continuous fetal monitoring, epidural analgesia, and obstetrical interventions.

Intervention Results: Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.

Conclusion: Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.

Setting: Beaumont Hospital, Royal Oak, an academic-community hybrid facility in southeastern Michigan

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Peer Review, Quality Improvement

Intervention Description: This study examined the cesarean section rates at a university hospital before and after the implementation of a quality improvement effort that included weekly review conferences to discuss all cesarean deliveries. The conferences, which began in 2010 and continued throughout the study period (2013) were attended by obstetric care providers, anesthesiology, and labor and delivery nurses. Of the deliveries included in the study, 1,677 occurred in the prereview period and 3,864 occurred in the postreview period.

Intervention Results: There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1-23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55-0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74-13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53-0.89). The increase in forceps deliveries and the decrease in cesarean deliveries were seen only in daytime hours (7 AM to 7 PM), that is, the shift that was covered by senior obstetricians.

Conclusion: Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Setting: Oregon Health & Science University Hospital

Population of Focus: women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, Peer-Review of Provider Decisions, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Neonatal Back-Transport Systems, Medical Staff Integration

Intervention Description: To improve outcomes and maximize resource utilization, a regionalized system for high-risk perinatal and neonatal care is recommended.

Intervention Results: There was a significant decrease of 63% in the number of VLBW births at level II hospital after intervention (p-value and statistical test not indicated). The annual number of maternal transports to level III hospital increased 258% after intervention from an average of 38 per year to 98. The authors do not comment on statistical significance of this result.

Conclusion: With this process we were able to maintain a single level III subspecialty center, increase high-risk maternal transport, decrease neonatal transport, and limit VLBW deliveries outside of the level III subspecialty center.

Study Design: QE: pretest-posttest

Setting: Ohio, TriHealth Hospital System Two level II and one level III hospital

Population of Focus: Total sample size not given for pretest and posttest periods.

Data Source: Data from the National Institute of Child Health and Human Development Neonatal Research Network registry, the Regional Perinatal Database, and hospital records.

Sample Size: Total sample size not given for pretest and posttest periods.

Age Range: Not specified